Elderwood Health Care at Birchwood

Based upon observations and staff interviews conducted during the standard survey, it was determined for 4 of 6 central bathing areas observed (on units #1, 2, and 3), the facility did not maintain a sanitary environment in regard to the maintenance of shower equipment. Specifically, 4 shower hoses in the central bathing areas were not equipped with required backflow prevention devices (a device to prevent contaminated water from entering the building plumbing system); a backflow prevention device was missing from one shower hose in each unit #1 and unit #3, and missing from two shower hoses in unit #2. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

During the building inspection conducted on January 21, 2010 between 9:15 AM and 12:53 PM, 4 of 6 shower hoses that extended to within one foot of floor level in the central bathing areas were observed to lack required backflow prevention devices:
- one was missing on unit #1;
- two were missing on unit #2;
- one was missing on unit #3.

When the Director of Maintenance was interviewed on January 21, 2009 at 10:00 AM, he stated he performed periodic environmental rounds, which included checking the shower rooms. He stated he had not paid attention to checking whether backflow prevention devices were present. He stated he believed a previous employee removed the devices after replacing the shower hoses.

In summary, the facility did not ensure a sanitary environment was maintained, due to missing backflow prevention devices on 4 shower hoses.

10NYCRR 415.5(h)(2)

Based on observations, record reviews, and staff interviews conducted during the standard survey, it was determined the facility did not maintain an effective infection control program designed to prevent the development and transmission of diease and infection for 1 of 4 residents (Resident #3) reviewed for pressure ulcers. Specifically, the facility did not ensure appropriate infection control technique was used when cleansing a pressure ulcer during a dressing change. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

Resident #3 had diagnoses including Parkinson's disease, dementia, and adult failure to thrive.

The Minimum Data Set (MDS) assessment, dated November 4, 2009, documented the resident had severely impaired daily decision making skills, needed total assistance with all ADLs (activities of daily living), had 2 Stage IV pressure ulcers, and 1 Stage III pressure ulcer.

The comprehensive care plan (CCP), dated November 11, 2009, documented the resident had a loss of cognition, and received palliative care related to end stage Parkinson's disease.

The registered nurse's (RN) wound/skin note, dated December 15, 2009, documented the pressure ulcer on the resident's spine was a healing Stage II ulcer.

The physician orders, dated January 11, 2010, documented to apply a NS (normal saline) wet to dry dressing to the unstageable pressure ulcer on the resident's spine every shift.

During a pressure ulcer dressing change observation on January 21, 2009 at 11:10 AM, the licensed practical nurse (LPN), washed her hands, and set up her wound care products on the overbed table on a clean pad. After donning gloves, she removed the old dressing from the pressure ulcer. The LPN sprayed the pressure ulcer with a skin cleanser, and using a gauze pad, patted the pressure sure ulcer from the outer edges inward to the center of the wound. When she finished cleansing the pressure ulcer, she applied a clean gauze pad soaked with NS to the area and secured it with hyperflex tape.

During an interview on January 21, 2010, the LPN stated she realized she should have patted the pressure ulcer dry from the center out, and normally that was what she did.

In summary, the facility did not ensure appropriate infection control technique was implemented during the resident's dressing change, when the LPN cleansed the pressure ulcer in a manner that could cause cross contamination of the pressure ulcer.

10NYCRR 415.19 (a)(1-3)

Based on staff interviews and record reviews conducted during the standard survey, it was determined for 2 of 17 residents reviewed for accident/incident investigations (Residents #1 and 8), the facility did not conduct a thorough investigation of injuries of unknown origin to determine if abuse or neglect occurred. Specifically, Resident #1 was found with a skin tear on her knee, and the facility did not conduct a thorough investigation to determine the origin of the injury. Resident #8 was found with an area of "deep ecchymosis" (bruising) on his chest. There was no documented evidence an investigation was conducted to determine the origin of the injury. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

1) Resident #8 had diagnoses which included dementia, anemia, and psychosis.

The Minimum Data Set assessment dated July 29, 2009, documented the resident had short term memory impairment and was moderately impaired cognitively. This assessment documented the resident's mental function varied throughout the day, he needed extensive assistance with dressing and bathing, and he was resistive to care.

The nursing notes dated October 8, 2009, documented the resident had an area of "deep ecchymosis" on his upper chest. The area was assessed by the Nursing Supervisor, the Unit Manager and the Assistant Unit Manager. These notes documented the following description; "broken blood vessel with visible valve through skin tissue noted at upper aspect of ecchymosis and presents that when vessel broke at valve blood pooled downward on chest tissue. Area is not caused by trauma. (Resident's) vascular system is fragile given age and tissue is thin so when vessel spontaneously breaks this will be seen."

Review of the resident's medical record revealed no documentation regarding the area of deep ecchymosis on the resident's chest in the physician progress notes.

Upon request, the facility was unable to provide an accident/incident investigation regarding the ecchymotic area on the resident's chest.

During an interview with the Assistant Unit Manager registered nurse (RN) on January 22, 2010, at 12:10 PM, she stated she remembered the certified nurse aide reporting the bruising on the resident's chest. She stated the area was assessed by the RN Unit Manager, the RN Supervisor and her, and physician was notified. The Assistant Unit Manager stated the end of the vein could be seen sticking out through the resident's skin. She said it did not look like trauma as the area was not "open or anything", and no treatment was needed.

During an interview on January 22, 2010, at 1:20 PM, the RN Supervisor stated she was asked by the RN Unit Manager to look at the bruised area. She said because the resident's skin was so fragile you could see the vein was ruptured and was leaking down, you could see that it was spontaneous. The RN stated the area was reported to the physician assistant (PA); she said there was no progress note from the PA regarding the area. She said she did not remember the exact size of the area, but it was not the size of the resident's whole chest. She said the cause was medical, due to the resident's age and condition. The RN said the Unit Manager (RN) told her the ecchymosis was not trauma, it was spontaneous, so there was not need for an accident/incident investigation.

The RN Unit Manager was not available for interview, as she was no longer employed by the facility.

In a telephone interview with the physician assistant on January 22, 2010, at 1:45 PM, he stated he remembered being told about the bruise on the resident's chest, but could not remember his assessment. He stated it should be documented in his notes in the resident's medical record. The PA said he did not think the bruising was from a fall. He stated one can not tell by looking at a bruise whether it was caused by trauma. The PA said it could not be assumed that the bruise on the resident's chest was a spontaneous injury; an investigation would have to be conducted.

In summary, the facility did not ensure a thorough investigation was completed, regarding the resident's injury of unknown origin, in order to determine whether abuse or neglect had occurred.

2) Resident #1 had a diagnosis of dementia.

A facility Accident/Incident Report, dated/timed December 27, 2009 at 11:15 PM, documented a licensed practical nurse (LPN) and a certified nurse aide (CNA) observed a bandage with "bloody drainage" on the resident's right knee. The resident was confused, and was not able to offer an explanation for the skin tear. The report noted the 3 PM to 11 PM Nursing Supervisor was notified.

During an interview on January 22, 2010 at 5 PM, the 3 PM to 11 PM, registered nurse (RN) Supervisor stated he was notified by phone of the resident's skin tear, as he was giving change of shift report to the 11 PM to 7 AM Supervisor. The RN stated he reported the information to the oncoming RN Supervisor. He did not examine the resident himself.

The same Accident/Incident Report, dated December 27, 2009 at 11:15 PM, documented the staff had noted the skin tear, which measured 3 centimeters (cm) x 3 cm, with no fresh bleeding, and a triple antibiotic ointment/Band-Aid had been applied prior to that shift (11 PM to 7 AM). The documentation noted the resident had dementia, and was unaware when or how the skin tear happened. This report documented the resident had no recent falls or injuries. The report documented a plan for prevention of future injuries which included: staff should use "care" when handling the resident, ensure "nails" are filed straight with no sharp edges, and check the resident's wheelchair/equipment for sharp edges. The report was signed by the 11 PM to 7 AM RN supervisor (who had received report on December 27, 2009 at 11 PM), the Unit Manager, the Director of Nursing, the Medical Director, and the Administrator.

There was no documented evidence nursing staff who worked with the resident prior to the discovery of her skin tear, were interviewed to determine the cause of the injury.

On December 28, 2009 at 1:40 AM, the registered nurse (RN) Supervisor documented the unit Team Leader (nursing staff) notified the 3 PM to 11 PM RN Supervisor at 11:15 PM the resident had a skin tear that was covered with a Band-Aid. The RN's note documented the skin tear was found by the Team Leader and a certified nurse aide (CNA) when they were providing care to the resident. The RN recorded she assessed the skin tear, which measured 3 cm x 3 cm. The RN's note documented the resident's environment appeared safe with no sharp objects. The resident did not know how the skin tear occurred, and was asleep prior to receiving care.

On December 28, 2009 at 1:25 AM, the physician ordered a treatment and dressing to the resident's skin tear. There were no physician orders related to the resident's skin tear prior to December 28, 2009.

The resident's Minimum Data Set (MDS) assessment, dated January 4, 2010, documented the resident's cognitive skills were moderately impaired, her decisions were poor, cueing/supervision was required, and she had short/long term memory problems.

The comprehensive care plan (CCP), dated January 22, 2010, documented staff were to ensure the resident's nails were filed straight with no sharp edges, and ensure there were no sharp edges on the resident's wheelchair/equipment.

During an interview on January 22, 2010 at 2:45 PM, the RN Unit Manager stated she had asked staff if they knew the origin of the resident's skin tear and no one she asked had seen it. The RN could not provide documentation of these interviews. She stated she had "assumed" the skin tear was caused by the resident's nails.

During an interview on January 22, 2010 at 3:20 PM, the Administrator stated a discussion was held between staff who believed the 3 PM to 11 PM supervisor conducted an investigation to determine the cause of the resident's skin tear. There was no documented evidence of these discussions or investigation.

During an interview on January 22, 2010 at 4:20 PM with the Administrator and the Director of Nursing (DON), the DON stated there was a discussion at the morning report, and the cause of the resident's skin tear was determined to be the resident's fingernails. There was no documented evidence provided of the discussion.

In summary, the facility did not ensure a thorough investigation was completed, regarding the resident's injury of unknown origin, in order to determine whether abuse or neglect had occurred.

10 NYCRR 415.4 (b)(1)(ii)

Based on record review and staff interviews conducted during the standard survey, it was determined for 1 of 12 sampled residents reviewed for physician services (Resident #10), the facility did not ensure medical staff reviewed the resident's total program of care. Specifically, the attending physician did not ensure the medication planned for Resident #10 (cranberry caplets) was ordered for the time period of December 2, 2009 to January 22, 2010. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

Resident #10 had diagnoses including dementia, and a history of urinary tract infections.

The resident's urine culture laboratory results, dated November 14, 2009, documented the resident had a urinary tract infection, showing greater than 100,000 CFU/ML (colony forming units per milliliter) of Escherichia coli (a bacteria) and greater than 100,000 CFU/ML of Proteus mirabilis (a bacteria) present in the urine.

A physician order dated November 16, 2009 was for Ceftin (an antibiotic) 250 milligrams (mg) twice a day for 5 days, for the urinary tract infection.

A physician progress note, dated December 2, 2009, documented the resident was seen last on November 4, 2009. This note documented the resident had no new issues, and had frequent urinary tract infections, "as most of our residents do." This progress note documented a list of the resident's current medications (which did not include cranberry caplets). The note documented an assessment/plan, which included "we will start cranberry caplets."

A review of the physician orders from December 2, 2009, through January 3, 2010, revealed no documented evidence cranberry caplets had been ordered.

A physician progress note, dated January 4, 2010, documented the resident was seen last by the physician in December 2009, and had no new issues. The progress note documented a list of the resident's current medications and did not include cranberry caplets. The note documented the resident had frequent urinary tract infections, and an assessment/plan, which included "we will start cranberry caplets".

A review of the physician orders from January 4, 2010, through January 20, 2010, showed no documented evidence the cranberry caplets had been ordered.

The comprehensive care plan, dated January 22, 2010, documented a goal of the resident would be free of signs/symptoms of urinary tract infections upon completion of antibiotic therapy. The interventions included medications would be administered as ordered by the physician and nurse practitioner.

During an interview on January 22, 2010 at 12:55 PM, the attending physician stated cranberry tablets decreased a person's chance of developing a urinary tract infection. She provided no rationale for not ordering the cranberry tablets, as documented in her progress notes.

In summary, the facility did not ensure medical staff reviewed the resident's total program of care, as the physician's plan for cranberry tablets was not implemented from December 2, 2009 to January 22, 2010.

10NYCRR 415.15(b)(2)(iii)